The objectives of this project are to test the feasibility and obtain preliminary efficacy data for a physician office-delivered smoking cessation intervention targeting smokers enrolled in Medicaid Managed Care Programs (MMCPs) in Ohio Appalachia. The smoking prevalence is 48% among Medicaid enrollees in Appalachia, which is more than twice as high as the state estimate (1). Two MMCPs serving the Ohio Appalachian region have agreed to work with us by supplying a list of providers and support for the project. The specific aims of this R21 proposal are to perform a qualitative study with physicians, office staff, and MMCP smokers to better understand: 1) physician and office staff attitudes, norms, and perceived behavioral control;and 2) how a scientifically-valid intervention should be incorporated into an MMCP office and delivered to patients. 2. To test the feasibility of a physician office-delivered intervention in promoting: 1) quit attempts and use of cessation pharmacotherapy among Appalachian MMCP enrollees;2) delivery of the 5A's by the MMCP physician offices;and 3) changes in physicians'attitudes and perceived behavioral control. 3. Exploratory: To examine the cost-effectiveness of delivering the intervention to MMCP enrollees. A two-phase design will be used for this study. In Phase I, qualitative research will be used to gain an understanding of the issues involved with implementing a comprehensive tobacco cessation program in MMCP physician offices. Physicians, their staff, and MMCP smokers will be recruited and asked to engage in qualitative interviews or focus groups. Phase II will consist of a pilot and feasibility test of the intervention targeting physician offices. The overarching goal of the intervention will be to promote systems-level changes in MMCP physician offices to promote smoking cessation among Medicaid enrollees. The intervention will include: 1) implementation of a tobacco-user identification system;2) education and training of physicians;3) periodic feedback to physicians;and 4) recruitment and training of an "office champion" to promote compliance with the intervention. For Phase II, a group-randomized trial will be used to pilot test the intervention in 8 randomly selected physician offices in Athens County, Ohio (4 offices will be randomized to the intervention and 4 to the control condition). From each physician office, a total of 30 MMCP smokers will be recruited as then come in for a medical appointment. Outcomes, which are quit attempts for 24 hours and use of pharmacotherapy, will be assessed among these participants at 3 months post-enrollment. PUBLIC HEALTH RELEVANCE: Public Health Relevance In Ohio Appalachia, 16% of adults are enrolled in the Medicaid program, and half of these individuals are current smokers. The research will provide important information to assist in reducing smoking among Medicaid enrollees in Ohio Appalachia. These findings may be generalizable to other rural and Appalachian communities in the United States.